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Treatment options for children with leg length discrepancy (LLD)

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When it comes to leg length discrepancy (LLD) in children, choosing the right treatment is crucial. Various factors like the cause of LLD, presence of bone deformities, the child’s age and the expected remaining growth, as well as the family’s preferences all play a role in determining the most appropriate approach.^1,2 Treatments for LLD range from non-surgical interventions to surgical procedures such as the use of intramedullary lengthening nails. While mild LLD may be managed conservatively, more severe cases often require surgical correction.¹ Read on to explore the treatment options available for managing LLD in pediatric patients and how to support recovery after treatment.

Non-Surgical Treatments for Leg Length Discrepancy

For children with a mild leg length discrepancy (less than 1-2 centimeters) and who do not have bone deformity, non-surgical treatments can be effective. These treatments, often referred to as “conservative” methods, are recommended when the risks of surgery outweigh the benefits of equalizing leg length.³

Observation: In cases where the LLD is minimal and the child has not yet reached skeletal maturity, observation is the most common approach. During observation, the pediatric orthopedic specialist will monitor the child’s growth usually every 6-12 months to assess if the discrepancy increases as the child grows.^4,5
Shoe Inserts & Lifts: Orthotic inserts placed inside shoes can be provided for children with small discrepancies. For children with more significant LLD and experiencing difficulty walking, or other problems due to LLD, shoe lifts may be prescribed, where an orthotist will alter a typical shoe by adding the appropriate external lift to the sole. Custom-made shoe lifts have to be replaced as the child’s foot grows. Shoe lifts can also be an interim solution to (at least partially) address leg length inequality until the child is old enough for surgical treatment.¹
Physical Therapy: It can play a critical role in managing LLD, especially in cases of functional leg length discrepancy caused by muscle imbalances and not by a bone size difference. For children with structural LLD (due to bone length differences), physical therapy is often used to prepare the body for surgery or aid recovery post-surgery.^6,7 Stretching and strengthening exercises may help improve gait and alleviate discomfort.

Surgical Treatments for Severe Leg Length Discrepancy

When the LLD exceeds 2 centimeters or severely affects a child’s mobility and quality of life, surgical interventions are typically recommended. Surgery aims to either stop the growth of the longer leg or lengthen the shorter leg.² The type of surgery selected depends on the child’s growth stage and the extent of the discrepancy.

Epiphysiodesis: For children who are still growing, epiphysiodesis is an option. There are different techniques, such as the percutaneous drilling method to permanently stop a growth plate, and reversible methods that only temporarily stop a growth plate but involve metal implants that must be removed once the LLD in corrected. Epiphysiodesis techniques do not involve cutting the bone, but the child must be skeletally immature for it to be applicable.⁸ Your surgeon can explain the advantages and disadvantages of epiphysiodesis to select the best technique for your child.
Bone Shortening: If a child has reached skeletal maturity (when bones stop growing), the longer leg may be shortened to match the shorter leg. This procedure involves removing a section of bone and securing the remaining parts with metal plates or intramedullary rods.⁹ With modern internal bone lengthening technology, acute bone shortening is typically reserved for patients that are not ideal candidates for limb lengthening.
Leg Lengthening Surgery: In cases of severe LLD, leg lengthening surgery may be the best option. This complex procedure involves cutting the shorter bone and gradually pulling the ends apart to allow for new bone to grow in the space between them.

Intramedullary lengthening nails: A popular option for leg lengthening is the use of intramedullary nails, like the Orthofix Fitbone™ Intramedullary Lengthening Nail, which are inserted inside the bone. These nails can gradually extend, allowing the bone to grow and correct leg length discrepancy. Unlike external fixators, intramedullary lengthening nails are placed internally, reducing the risk of infection and providing a more discreet solution that is better tolerated by patients.
External fixators: Use of external frames that connect to the bone through the skin with pins and wires is the classic method of limb lengthening and used for several decades before the advent of modern internal bone lengthening devices like Fitbone. They may be the ideal option for patients who have a more complex limb length discrepancy that also involves significant angular and rotational deformity. External fixators may also be the best option for younger children that the Fitbone cannot fit inside their bone.

Recovery and Rehabilitation After Leg Length Discrepancy Surgery

Recovery after leg length discrepancy surgery depends on the type of procedure and the extent of the discrepancy corrected. Physical therapy plays a critical role during recovery. If intramedullary lengthening nails or external fixators were used, weight-bearing restrictions may be applied during the initial stages of recovery.

Limb lengthening surgery requires an extended period of rehabilitation. During distraction and consolidation, extensive physical therapy is essential to maintain joint motion, regain muscle strength and restore proper walking ability. ^2,9

Conclusion

Every child with leg length discrepancy requires an individualized treatment plan, tailored to their specific needs, growth potential, and the goals of their family. Consulting with a pediatric orthopedic specialist is the first step in exploring both surgical and non-surgical options. Many pediatric orthopedic surgeons perform epiphysiodesis surgery, however it typically requires additional training and expertise to perform limb lengthening procedures. Together, you and your doctor can determine the best course of action to improve your child’s quality of life.^2,3

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References